Articles, devices, and methods for pelvic surgery

ABSTRACT

Described are implants, tools, and related methods, for use in pelvic surgery to treat conditions such as prolapse and incontinence, including one embodiment of a method that uses a transcoccyx tissue path; other embodiments that use particular implants with various features relating to, e.g., end portions; and other embodiments relating to particular tools.

PRIORITY CLAIM

The present non-provisional patent Application claims priority under 35USC §119(e) from U.S. Provisional Patent Applications having Ser. No.60/668,287, filed on Apr. 5, 2005, by Hodroff and titled VAGINAL VAULTPROLAPSE, and 60/668,397, filed on Apr. 5, 2005, by Cox et al. andtitled ARTICLES, DEVICES AND METHODS FOR PELVIC SURGERY, wherein theentirety of said provisional patent applications are incorporated hereinby reference.

FIELD OF THE INVENTION

Described herein are features of surgical articles, surgical methods,and surgical tools, for use in the field of urogenital surgery, e.g., toinstall support devices for use in treating vaginal vault prolapse,incontinence, etc.

BACKGROUND

Medical conditions of urinary incontinence and pelvic prolapse areconditions of great importance. An aging population can be prone to suchconditions.

Urinary incontinence and pelvic prolapse are related to tissues of thepelvic region such as the bladder, urethra, and the vaginal vault.Pelvic prolapse develops when intra-abdominal pressure, muscle failure,a surgical procedure such as a hysterectomy, or other factors, allow orcause a pelvic organ such as the vagina to become displaced. Within thegeneral category of pelvic organ prolapse, specific types include vaultprolapse (apical) such as enterocele; cystocele (anterior); rectocele(posterior); and combinations of these.

Various techniques have been designed to correct or ameliorate vaginalvault prolapse and its symptoms, with varying degrees of success.Nonsurgical treatments involve measures to improve the factorsassociated with prolapse, including treating chronic cough, obesity, andconstipation. Other nonsurgical treatments may include pelvic muscleexercises or supplementation with estrogen.

A variety of surgical procedures have also been attempted for thetreatment of pelvic conditions such as vaginal vault prolapse andurinary incontinence. See for example U.S. patent application Ser. No.10/834,943, entitled “Method and Apparatus for Treating Pelvic OrganProlapse,” filed Apr. 30, 2004, and Ser. No. 10/306,179, entitled“Transobturator Surgical Articles and Methods,” filed Nov. 27, 2002, theentireties of each of these two patent applications being incorporatedherein by reference. Such patent applications describe articles andmethods for treating incontinence and pelvic organ prolapse by use of asupport member for supporting specific tissue. U.S. application Ser. No.10/834,943, for example, discusses a support member that includes acentral tissue support portion and two end portions, and related methodsfor implantation. The central tissue support portion can be attached attissue of a prolapsed organ, e.g., at the posterior of the vaginalvault. The end portions of the support member are then positionedthrough respective tissue pathways to place the support member in atherapeutic position for treatment of the prolapsed organ.

SUMMARY

The invention includes various features of pelvic surgical procedures,implants, and tools for surgical implantation procedures.

In one respect the invention relates to surgical methods that place anend portion of an implant through a region near the coccyx bone, i.e., a“coccyx” or “transcoccyx” tissue path. The invention also relates todevices, including tools and implants, that may be useful for treatmentsaccording to this “transcoccyx method,” but that may also be useful forother treatments, and for other installation methods.

For example, described are tools for surgically implanting an implant.The tools may be useful for treatments according to the “transcoccyxmethod,” but may also be useful for other treatments and for otherinstallation methods. Likewise, the tools may be useful for installingimplants as described herein, but they may also be useful for installingother implants.

The invention includes any one or more of the above discussed implants,tools, or methods, any of which can be used separately, or in anypossible combination, as will be understood based on the followingdescription.

According to certain embodiments an implant can be used to treat vaginalvault prolapse. The support member can include a central portion thatcan be attached to tissue of the vaginal vault, and two end portionsattached to the central portion. The implant can be used to placevaginal vault tissue in a therapeutic position for treatment of vaginalvault prolapse by attaching the central portion of the support member totissue of the vaginal vault and attaching the end portions to separatelocations for positioning or supporting the prolapsed tissue. Certaininventive methods involve placement of a support member to supportprolapsed tissue, including placement of an end portion of the supportmember at a location proximal to the coccyx bone, e.g., throughischiococcygeous (i.e., “coccygeous”) or iliococcygeous muscle lateralto the coccyx bone. Exemplary tissue paths can initiate from a regionsurrounding vaginal vault tissue and can extend past the rectum to alocation proximal to the coccyx bone. The end portion of the supportmember can generally be guided through such a passage prepared in muscleor other tissue, past the rectum, past and proximal to the coccyx bone,and then through an external incision of the epidermis.

Embodiments of the inventive methods attach a tissue support portion ofan implant to tissue of a vaginal vault, and one or two end portions,either unilaterally or bi-laterally, near the coccyx bone (e.g.,proximal to the tip of the coccyx). Other placement of a tissue supportportion, and other tissue paths, may be useful for use with inventiveimplants, methods, and tools described herein.

In one aspect, the invention relates to a method for supporting vaginaltissue. The method includes: providing an implant comprising a tissuesupport portion and an end portion extending from the tissue supportportion; creating a vaginal incision; placing the tissue support portionin contact with vaginal tissue in a position to support the vaginaltissue; and producing a tissue path between the position of the tissuesupport portion and an exterior incision. The tissue path passes throughtissue of a coccyx region bounded by an upper edge of a sacrospinousligament, a tip of a coccyx bone, a point approximately 2.5 centimeterslateral to the tip of the coccyx bone, and an ischial spine. The endportion is extended through the tissue path to the external incision.The implant may be any implant as described herein or otherwise, and mayor may not include features of implants and end portions as describedherein, such as a dilator, sheath, etc. The method may include the useof a tool, the tool being as specifically described herein or otherwise.

In another aspect, the invention relates to a pelvic implant. Theimplant may be useful for supporting pelvic tissue and can includesupportive portions consisting of: a central support portion having twoelongate end portions extending from the central support portion. Thecentral support portion has a width greater than a width of the endportions. The implant also includes a shorter end portion that has alength that is shorter than a length of a longer end portion. Theimplant may optionally include one or more sheath, each at leastpartially containing an end portion, and a dilator for each end portion.The implant may be implanted into a patient by any method such as atranscoccyx method described herein, or otherwise. The implant may beused to treatment any pelvic condition.

Another aspect of the invention relates to a pelvic implant thatincludes: a tissue support portion and an elongate end portion extendingfrom the tissue support portion, a dilator attached to a distal end ofthe end portion, and an elongate sheath surrounding at least a portionof the end portion. A distal end of the sheath is also attached to thedilator, and the end portion includes a passage between a locationinside of the sheath to an internal surface of the dilator. The implantmay be implanted into a patient by any method such as a transcoccyxmethod described herein, or otherwise. The implant may be used totreatment any pelvic condition.

In another aspect, the invention relates to a method of connecting adilator to an end portion of an implant. The method includes: providingan elongate end portion having a distal end, providing an elongatesheath surrounding at least a distal portion of the end portion,laterally curling a distal portion of the sheath and end portion, andmolding a dilator over the curled sheath and end portion. The methodresults in a molded dilator assembly that includes the dilator molded todistal ends of each of the sheath and end portion. The molded dilatorassembly includes a passage that allows access from an interior locationof the sheath to an internal surface of the dilator. A needle can passthrough the passage to allow the tip of the needle to engage an internalsurface of the dilator. The implant may be implanted into a patient byany method such as a transcoccyx method described herein, or otherwise,and with any type of needle. The implant may be used to treatment anypelvic condition.

In yet another aspect, the invention relates to a surgical tool thatincludes a handle comprising a longitudinal axis and a two-dimensionalelongate needle extending from the handle. The elongate needle includes:a first curved portion extending longitudinally from the handle, thefirst curved portion having a first radius of curvature and a firstarclength; a second curved portion extending from a distal end of thefirst curved portion, the second curved portion having a second radiusof curvature and a second arclength that are different from (e.g., lessthan) the first radius of curvature and first arclength; and a straightportion extending from a distal end of the second curved portion to aneedle tip. The tool may be useful for transvaginal “inside-out”procedures for implanting a pelvic implant, e.g., using a transcoccyxtissue path as described herein, or using a different tissue path.

In yet another aspect, the invention relates to a pelvic implant forsupporting vaginal tissue. The implant includes: a tissue supportportion having an anterior portion, a posterior portion, and amid-portion between the anterior portion and the posterior portion; atleast two end portions extending from one or more of the mid-portion orthe anterior portion, and only one end portion extending from theposterior portion. The implant and end portions may optionally includefeatures of sheaths, dilators, etc., as described herein.

In another aspect, the invention relates to an implant comprisingsupportive portions consisting of: a tissue support portion, and one endportion extending from the tissue support portion. The implant and endportion may optionally include features of sheaths, dilators, etc., asdescribed herein.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates an example of an implant according to the invention.

FIG. 2 illustrates an example of an implant according to the invention.

FIG. 3 illustrates an example of an implant according to the invention.

FIG. 4 illustrates an example of an implant according to the invention.

FIG. 5 illustrates an example of a combination of an implant and aneedle, according to the invention.

FIG. 6 illustrates an example of a combination of an implant and aneedle, according to the invention.

FIG. 7 illustrates an example of a distal portion of end portion of animplant of the invention.

FIG. 8 illustrates a die useful for preparing a dilator describedherein.

FIG. 9 illustrates a die useful for preparing a dilator describedherein.

FIG. 10 illustrates a die useful for preparing a dilator describedherein.

FIG. 11 illustrates pelvic anatomy with reference to a transcoccyxtissue path according to exemplary procedures of the invention.

FIG. 12 illustrates pelvic anatomy with reference to a transcoccyxtissue path according to exemplary procedures of the invention.

FIG. 13 illustrates pelvic anatomy with reference to a transcoccyxtissue path according to exemplary procedures of the invention.

FIG. 14 illustrates pelvic anatomy with reference to a transcoccyxtissue path according to exemplary procedures of the invention.

FIG. 15 illustrates pelvic anatomy with reference to a transcoccyxtissue path according to exemplary procedures of the invention.

FIG. 16 illustrates pelvic anatomy with reference to a transcoccyxtissue path according to exemplary procedures of the invention.

FIG. 17 illustrates an exemplary tool according to the invention.

FIG. 18 illustrates an exemplary combination according to the invention.

FIG. 19 illustrates a step of a method of the invention.

FIG. 20 illustrates a step of a method of the invention.

FIG. 21 illustrates an exemplary combination according to the invention.

FIG. 22 illustrates an exemplary implant according to the invention.

FIG. 23 illustrates an exemplary implant according to the invention.

FIG. 24 illustrates an exemplary implant according to the invention.

All drawings are schematic and not to scale.

DETAILED DESCRIPTION

According the invention, a surgical implant is used to treat a medicalcondition, including the specific examples of implanting a supportmember (“implant”) to treat a pelvic condition such as vaginal vaultprolapse or incontinence (male or female). Described herein are variousfeatures of surgical implants, surgical tools, and surgical methods,useful for installing implants.

An implant can be implanted to treat disorders such as urgeincontinence, mixed incontinence, overflow incontinence, functionalincontinence, prolapse (e.g. vaginal), enteroceles (e.g. of the uterus),rectoceles, cystocele, and anatomic hypermobility.

In general, an implant can include a tissue support portion that can beused to support a pelvic tissue such as the urethra or vaginal tissue.During use, the tissue support portion is typically placed in contactwith and attached to tissue to be supported, such as with a suture. Animplant can additionally include one or more end portions attached tothe tissue support portion. See, e.g.: U.S. patent application Ser. Nos.10/834,943; 10/306,179; U.S. Ser. No. 11/347,063, filed Feb. 3, 2006,entitled PELVIC IMPLANTS AND RELATED METHODS; U.S. Ser. No. 11/347,596,filed Feb. 3, 2006, entitled SURGICAL IMPLANTS AND RELATED METHODS ANDSYSTEMS; and U.S. Ser. No. 11/346,750, filed Feb. 3, 2006, entitledTRANSOBTURATOR SURGICAL ARTICLES AND METHODS; the entireties of each ofthese being incorporated herein by reference.

An implant may include sections that are synthetic or of biologicalmaterial (e.g., porcine, cadaveric, etc.). End portions may be, e.g., asynthetic mesh such as polypropylene. The tissue support portion may besynthetic (e.g., a polypropylene mesh) or biologic. Examples of supportmember products that are sold commercially include a number sold byAmerican Medical Systems, Inc., of Minnetonka Minn., under the tradenames Apogee® and Perigee® for use in treating pelvic prolapse(including vaginal vault prolapse, cystocele, enterocele, etc.), andSparc®, Bioarc®, and Monarc® for treating urinary incontinence.

Exemplary implants can include a tissue support portion for placing incontact with tissue to be supported, and one or more “extension”portions (or “end portions”), the tissue support portion being useful tosupport a specific type of pelvic tissue such as the urethra, bladder,or vaginal tissue (anterior, posterior, apical, etc.). The tissuesupport portion can be sized and shaped to contact the desired tissuewhen installed, e.g., as a sling, to contact and support tissue. Atissue support portion that is located between two or more extension orend portions is sometimes referred to herein as a “central supportportion.”

End portions are elongate pieces of material that extend from the tissuesupport portion and are connected to the tissue support portion, usefulto attach to other anatomical features and thereby provide furthersupport for the tissue support portion and the supported tissue. One ormultiple (e.g., one, two, or four) end portions can extend from thetissue support portion as elongate “ends,” “arms,” or “extensions,” thatare used to attach to other anatomy, such as by extending through atissue path to an external incision or to an internal anchoring point.

Dimensions of an implant can be as desired and useful for any particularinstallation procedure or treatment, and to support a specific tissue ortype of tissue. Exemplary dimensions can be sufficient to allow thetissue support portion to contact tissue to be supported, and to allowone or more end portion to extend from the tissue support portion to adesired anatomical location to allow the end portion be anchored tosupport the tissue support portion.

A tissue support portion for contacting and supporting tissue canoptionally and normally be of a width that is greater than a width of anend portion. For an implant that includes either a single end portion oronly two end portions, an increased width of a tissue support portionmay take the form of one or two lateral extensions that extend the widthof the central support portion in at least one direction, beyond thewidth of an end portion. Optionally a tissue support portion may includetwo lateral extensions in each of an anterior lateral direction and aposterior lateral direction, e.g., relative to the width of an endportion or portions. A portion of a tissue support portion that isbetween an anterior extension and a posterior extension can beconsidered a mid-portion.

A tissue support portion should be sized and shaped to an overall areafor contacting tissue being supported. The tissue support portion is ofsufficient length to at least partially surround or otherwise be incontact with pelvic tissue to be supported. Various shapes and sizes areuseful, and the particular shape can depend on the intended application,e.g., to treat incontinence, vaginal prolapse, etc.

Generally, exemplary lengths of a tissue support portion can be in therange from 0.5 to 5 centimeters, such as from 0.7 to 4 centimeters.Exemplary widths of a tissue support portion can be in the range from 1to 15 centimeters, such as from 2 to 12 centimeters. The shape of thetissue support portion can also be varied, depending on the intendedapplication, and may be square, rounded, angled, rectangular, etc.

A width of an end portion can be a width useful for implanting theimplant and for providing desired strength and fixation propertiesduring and after implantation and optional tensioning of the sling.Typical widths of end portions can be in the range from 0.5 to 3centimeters, e.g., from 0.8 to 2 centimeters. End portions can typicallyhave a uniform or substantially uniform width along the length, normallynot varying by more than about 25 percent of the average width along thelength of the installed portion of the end portion.

An example of a particular type of pelvic implant is the type thatincludes supportive portions including or consisting of a centralsupport portion and two elongate end portions extending from the centralsupport portion. The term “supportive portions” refers to portions of animplant that function to support tissue after the implant has beenimplanted, and specifically includes end portions and tissue supportportions, and does not include optional or appurtenant features of animplant such as a sheath or dilator.

According to particular embodiments, end portions may be of the same orof different lengths. End portions of different lengths may be usefulfor certain types of surgical implantation procedures where one endportion is inserted internally into a patient during an earlier step,and a second end portion is inserted in a later step, optionally usingthe same tool for both steps. As an example, a procedure describedherein for treating a female pelvic condition using a transvaginal“transcoccyx” tissue path (e.g., an “inside-out” transcoccyximplantation method as described herein), may benefit from the use of animplant that includes two end portions of different lengths. One endportion may be shorter, for first insertion into a patient andadjustment into position, and a second end portion may be longer forinsertion after the shorter end portion. The longer end portion,inserted second, includes an extended length that allows the surgeon tomanipulate the second portion while the first portion is alreadyinserted and therefore is immobile.

The lengths of end portions can be measured as from a location where anend portion meets a tissue support portion, to an opposite distal end ofan end portion such as where the end portion meets a dilator. Exemplarylengths of a longer end portion may be from 1 to 4 inches longer than ashorter end portion, e.g., from 1 to 3 inches longer. Examples ofspecific end portion lengths may be, e.g., from 7 to 11 inches for ashorter end portion and from 8 to 12 inches for a longer end portion(e.g., from 9 to 11 inches).

FIG. 1 illustrates an example of an implant, 2, that has supportiveportions consisting of a central support portion 12 and two end portions4 and 6. Central support portion 12 includes anterior lobe 16 andposterior lobe 14 (with a mid-portion between the two lobes). Endportions 4 and 6 connect to central support portion 12 and extend inopposite directions to distal ends that include dilators 8 and 10, whichboth point in directions that are parallel to the length-wise axis ofend portions 8 and 10. As shown (not necessarily to scale), end portion4 has a length that is less than the length of end portion 6, e.g., by adifference in the range from 1 to 4 inches.

In another aspect, the invention can relate to the design and use of asupport member (implant) that includes only one end portion, e.g., theimplant being useful for treating vaginal vault prolapse. Such assingle-sided or “one-legged” implant is illustrated in FIGS. 2 and 3,which illustrate an implant that may be useful for vault support andthat has only one support arm (end portion) attached to a tissue supportportion. Referring to FIG. 2, implant 20 includes supportive portionsthat consist of tissue support portion 22 and end portion 24. Endportion 24 is attached to give a 90 degree angle between length-wiseaxis 28 of end portion 24 and lateral axis 30 of tissue support portion22, but may alternately create a non-perpendicular angle.

A different example of a feature of a useful implant can be an endportion extended from a tissue support portion at an angle that is notperpendicular to a lateral axis of the tissue support portion. Anon-perpendicular angle between a lateral axis of the tissue supportportion and a length-wise axis of an attached end portion can allow thetissue support portion to be in contact with tissue, while the endportion extends through or to desired anatomy, without causing a fold orbend in material at the end portion or at the transition between an endportion and a tissue support portion. The angle (measured while theimplant lies flat) may be as desired for a particular procedure, but anangle of approximately 45 degrees may be useful for treatment of vaginalprolapse by placement of the tissue support portion at the vaginal apexand extension of an end portion through a tissue path that includes acoccyx region location as described herein. The angle may be, forexample, between 40 and 50 degrees, e.g., from 35 to 55 degrees, or from30 to 60 degrees, as measured from between a line defined by the lateralaxis of the tissue support portion and a length-wise axis of the endportion, while the implant lies flat.

FIG. 3 illustrates an embodiment of an implant having an end portion ata non-perpendicular angle to a tissue support portion as described.Implant 40 includes supportive portions that consist of tissue supportportion 42 and end portion 44. End portion 44 is attached to give a45-degree angle between length-wise axis 48 of end portion 44 andlateral axis 46 of tissue support portion 42. While FIG. 3 shows animplant that includes only one end portion, the same feature of an endportion angled relative to a tissue support portion could be used alsowith an implant that includes supportive portions consisting of acentral support portion and two end portions, such as illustrated atFIG. 4.

According to other embodiments of implants, various additionalcomponents and features can be incorporated for added utility orconvenience, such as components and features that facilitate surgicalimplantation. For instance, a tensioning member (e.g., suture) may beattached to an implant along a portion or entire length of an endportion for use in adding tension or in positioning an implant or aportion (e.g., end portion) of an implant. A tensioning suture may beattached at one or multiple attachment points along a length of an endportion. Multiple sutures may be used, such as two or more sutures alonga length of one end portion, for added tensioning effect. Alternately orin addition, end portions of an implant can include reinforcement ormultiple layers. See, e.g., Assignee's copending U.S. patent applicationSer. No. 11/347,063, and U.S. Ser. No. 11/347,596. Other embodiments ofthe invention do not require and can specifically exclude a tensioningmember such as a suture, multiple layers for end portions, and edgeextension reinforcement for end portions.

Yet another optional component of an implant can be a sheath such as aplastic, transparent elongate tube, or the like, that can cover aportion or entire length of an end portion of an implant to facilitateinstallation by allowing a surgeon to apply tension or pressure on thesheath, optionally to indirectly pressure or tension the end portion ortissue support portion.

An end portion of an implant may also optionally include a connector or“dilator” at an end distal from a tissue support portion, the dilatorbeing able to cooperate with an insertion tool (e.g., needle, tunneler,etc.) during a surgical procedure to either push or pull the connectorthrough tissue using the end of the insertion tool. For example, aconnector may be a rigid plastic tip or dilator attached to a distal endof an end portion of an implant, and constructed to attach to an end ofan elongate insertion tool by snapping, threading, or otherwise securingto the end of the insertion tool. The insertion tool can then be used topush or pull the connector through a tissue passage to also bring theend portion of the implant through the tissue passage.

A dilator can be oriented as desired relative to an end portion, and mayoptionally be oriented to point in a direction that is approximatelyparallel to a length-wise axis of an end portion (when the end portionof the implant lies flat) as illustrated, e.g., at FIGS. 1 and 4. Forexample, exemplary dilators may include a major dimension that willalign the dilator along a tissue path as the dilator dissects the tissuepath or traverses a pre-formed tissue path. The major dimension may alsoalign with an insertion tool to which the dilator is attached. Accordingto certain end portions and dilator embodiments, the major dimension ofa dilator can still further be aligned with a length-wise axis of an endportion, e.g., in a manner to allow the dilator to be pushed throughtissue by use of a needle that engages the needle from behind thedilator and pushes the dilator through the tissue path.

FIG. 4 shows implant 50 that includes end portions 52 and 54, each ofwhich is enclosed in a plastic sheath 56 and 58, respectively. Eachsheath 56 and 58 includes end opening 57 and 59, respectively. Asillustrated, plastic sheath 56 and end portion 52 are longer in lengthcompared to end portion 54 and sheath 58. Sheaths 56 and 58 includeapertures 63 and 62, respectively, located on a side of each sheath toallow a needle to be inserted into the sheath. Distance (d) between eachaperture 63 and 62 and each dilator 60, is equal (e.g., within 5percent), even though sheath 56 is longer than sheath 58. The equallength (d) allows a single needle of one length to be inserted into eachend portion so that a tip of the needle engages a dilator 60, while thesame amount (length) of needle is located inside each of the twodifferent sheaths.

Still referring to FIG. 4, with regard to methods described herein, aneedle (not shown) can be inserted into sheath 58 through aperture 62and the tip of the needle can be led internally within the passage ofsheath 58 to engage dilator 60 at the distal end of end portion 54, fromwithin the sheath. The tip of the needle becomes located in internalspace 61 (drawn as dashed lines) of dilator 60. This engagement betweena dilator and needle tip is generally shown in FIG. 5. After the needleis used to surgically position end portion 54 as desired, the needle canbe removed from sheath 62 and the same needle can be inserted into sideaperture 63 of sheath 56 (both being located outside of the patient) andled internally through sheath 56 to engage dilator 60 at internal space61. This second end portion and needle assembly can then be surgicallyimplanted in the patient. Distance (d) for each of sheaths 56 and 58having different overall lengths is equal so that a single needleinserted into each sheath will extend through the same distance (d) ofeach sheath, to engage a dilator.

Alternately, only the longer sheath need have a side aperture forinsertion of a needle. In such an embodiment, the total length of theshorter sheath between dilator and end opening can be equal to thedistance between dilator and aperture for the longer sheath. A needlecan be inserted into the end opening of the shorter sheath and the sameneedle can be inserted into the aperture of the longer sheath, and thesame length of needle is still inserted into each sheath.

FIG. 5 illustrates a combination of a dilator and a needle wherein theneedle engages the dilator in a manner that allows the needle to pushthe dilator to form a tissue path or to pass the dilator through apreformed tissue path. FIG. 5 shows needle 100, including threaded tip102 engaged with dilator 104. Dilator 104 is also attached to a distalend of end portion 110 of an implant. Threads 106 are located on tip 102of needle 100, to allow a frictional engagement with inside surface 105of dilator 104; inside surface 105 of dilator 104 may not includeopposing threads, but the size of the internal space may allow goodfrictional engagement between threads 106 and surface 105 of dilator104. Threads 106 allow for a removable engagement between dilator 104and tip 102.

As illustrated in FIG. 5, tip 102 engages dilator 104 in a directionthat allows needle 100 to push dilator 104 in direction 108 (i.e., as aline extending from the end of needle 100), and to thereby pull endportion 110 through a tissue path. Afterward, still within a surgicalimplantation procedure, dilator 104 can be removed from threaded tip 102and tool 100 can optionally be used to engage a second dilator at asecond end portion of an implant, if desired, for placement of thesecond end portion within another tissue path. End portion 110illustrated in FIG. 4 is not contained by a sheath, but a sheath couldbe used as discussed elsewhere in the present description, with needle110 being inserted into the sheath to engage internal surface 105 ofdilator 104.

FIG. 6 illustrates a needle and implant configuration wherein the needleis contained inside of a sheath. Needle 70, having tip 72, has beeninserted into side aperture 63 of transparent plastic sheath 56, thesheath also containing end portion 52 of an implant. The arrangementplaces needle 70 and end portion 52 next to each other inside of sheath56, for the length between side aperture 63 and dilator 60. The needlecan be used to push dilator 60 and end portion 52 to form or traverse atissue path, such as with dilator 60 becoming extended from an externalincision and allowing dilator 60 to be removed from tip 72 and needle 70to be removed from the inside of sheath 56. The same needle 70 can then,optionally, be used to place a second end portion of the implant (e.g.,end portion 54 as shown in FIG. 5), into a second tissue path, ifdesired.

A distal end of an implant that includes a dilator, such as illustratedat FIGS. 1, 4, 5, and 6, advantageously are pushable through a tissuepath using a needle engaged with the dilator at the side of the dilatorthat is attached to the distal end of an end portion. In addition, thedilator, sheath, and end portion assembly has a relatively low profile,meaning that it is somewhat streamlined and of a reduced or minimizedcross section, which allows for ease of movement through a tissue path.The assembly can be prepared to exhibit a low profile based on themanner by which the distal ends of the sheath and end portion areassembled and connected to the dilator.

FIG. 7 shows details of this streamlined or “low profile” endconfiguration. End 120 includes end portion 122 (a mesh) within sheath124, and connected to dilator 126. As assembled, distal end region 128includes a lateral curl or fold of the assembled end portion 122 andsheath 124, meaning the assembled pieces are together bent into an atleast partial curve or coil around a co-extending lengthwise axis (130)of the sheath 122 and end portion 124. Axis 130 is also parallel to amajor dimension (length) of dilator 126, and is also aligned with thedirection in which the dilator can be pushed through a tissue path. Aneedle can be inserted into the interior of sheath 124, such as througha side aperture in the sheath, through an end opening in the sheath, or,if desired, by puncturing the sheath using the tip of the needle. Oncethe needle is inside of the sheath, a low profile end configurationallows the tip of the needle to pass along an internal length of thesheath and become engaged with the interior portion of the dilator fromthe direction of the sheath, such as by engaging an internal surface ofhollow space 127 of dilator 126.

Another optional feature of a dilator is illustrated at FIG. 7, which isfins or extensions 129 of dilator 126. Extensions 129 extend in adirection away from lengthwise axis 130, to allow a surgeon to gripdilator 126 with surfaces of extensions 129 and turn dilator 126 aroundaxis 130. While these engaging surfaces are shown as fins, any otherextension or non-circular cross section of dilator 126 (when viewedalong axis 130) can be useful to allow a surgeon or other user to twistdilator 126 into engagement with a tip of a needle (not shown)particularly for use in twisting a dilator to engage a threaded needletip.

An implant as described can be implanted with the use of a surgical toolthat includes an elongate needle portion (“needle”) and a handle. Thedistal end or tip of the needle may be adapted to interconnect with thesupport member so the support member can be manipulated by the toolduring installation of the support member. As described herein, thedistal end of an end portion may include a tip such as a plastic tip(dilator) that connects to the end of the needle of a tool. The dilatorcan removably connect to the end of the needle in a fashion that resistsremoval during a surgical procedure, such as by snapping, using athreaded engagement, or otherwise removably engaging to the end of thetool (tip of the needle). A removable engagement is not a permanentengagement, but allows the tool to engage the dilator and be used toimplant an end portion, then allows removal of the dilator from thetool, and then allows the tool to engage a second dilator on a secondend portion of the same implant to allow the tool to be used to implantthe second dilator through a second tissue path. The description of adilator that can “removably” engage a tool does not include dilatorsthat engage a tool and can be removed only by damage to the dilator, endportion, tool, or a sheath. As described, the “removable” engagementallows for a tool to be used during surgery to engage one dilator forinsertion of the dilator through a tissue path, allows the tool to beremoved from the dilator without substantial effort or damage to theimplant or tool, and then allows the tool to engage a second dilator forimplantation.

According to specific aspects of this description, a support member canbe used to support vaginal vault tissue in a therapeutic position fortreatment of vaginal vault prolapse, by attaching the tissue supportportion of the support member to vaginal tissue and attaching an endportion or portions to separate locations to position or support thetissue. According to the invention, the end portion is passed through atissue path that extends from the tissue support portion to an exteriorincision exterior to a “coccyx region” of the patient. Specifically, thetissue path extends internally through tissue of a “coccyx region”bounded on one edge along the sacrospinous ligament (optionally eitherincluding or not including the sacrospinous ligament), another edgealong the vertical side edge of the coccyx bone, another edge defined bya line from a tip of the coccyx bone to a point lateral to the tip byabout 2.5 centimeters, and another edge that extends from that lateralpoint to the ischial spine.

One embodiment of a coccyx region 206 is shown at FIG. 11, which showssacrum 200, sacrospinous ligaments 202 on each side of sacrum 200, andalso connected to ischial spines 204. The lower tip 212 of coccyx bone208 defines one corner of coccyx region 206 (in dashed lines). Ischialspine 204 defines another corner. The top edge of the connection ofsacrospinous ligament 202 to sacrum 200 defines a third corner. Coccyxregion 206 extends generally from the tip of the coccyx bone, along aside edge 209 of coccyx bone 208 and continuing along a lower side edgeof sacrum 200 to the top edge of sacrospinous ligament 202, then acrossto ischial spine 204. The lower boundary, shown as the dashed linebetween ischial spine 204 and the tip 212 of coccyx 208, is not exactlystraight between these points but goes from tip 212 through a point 210that is approximately 2.5 centimeters lateral of tip 212, then furtherlaterally and upward to ischial spine 204. The pudendal complex (notshown) travels laterally at a location that is above the upper edge ofsacrospinous ligament 202, and is to be avoided.

A more specific coccyx region that can be a preferred coccyx region fora tissue path, is shown at FIG. 12, which shows anatomy similar to FIG.11, but illustrates coccyx region 220 bounded by the lower edge ofsacrospinous ligament 202, ischial spine 204, point 210 about 2.5 cmlateral to tip 212 of coccyx bone 208, and tip 212 of coccyx bone 208.

Yet another embodiment of a preferred region for a tissue path isillustrated at FIG. 13 as region 221. Region 221 is generally the arealateral of either vertical edge of the coccyx bone, e.g., up to about2.5 centimeters lateral of angled vertical edge 209 from bottom tip 212of coccyx bone 208 to the top horizontal edge of the coccyx boneadjacent to the sacrum, e.g., a region bounded by a vertical edge of thecoccyx bone between a tip of the coccyx bone at the bottom and a loweredge of a sacrum at the bottom, and a line 2.5 centimeters laterallyfrom that edge of and parallel to the edge. As shown in FIG. 13, coccyxregion 221 extends laterally a distance of up to 2.5 centimeters,including area lateral to the coccyx bone between an upper corner ofcoccyx bone 208 and tip 212.

As shown in FIG. 13, coccyx regions 221 may include a lower portion ofsacrospinous ligament 202 lateral of each side of coccyx bone 208.According to different embodiments of region 221 and methods of theinvention, a tissue path may be through this lower portion ofsacrospinous ligament 202, or alternately a tissue path may be belowthis sacrospinous ligament, somewhere within region 221 and below thelower edge of sacrospinous ligament 202.

Exemplary methods and devices involve placement of a support member tosupport vaginal or other pelvic tissue with placement of an end portionat a location proximal to the coccyx bone. A tissue path as describedherein, passing through a coccyx region, may be referred to herein as a“coccyx tissue path” or a “transcoccyx tissue path.” Exemplary suchtissue paths may extend through a coccyx region by also traversingischiococcygeous muscle, iliococcygeous muscle, or possibly both,preferably avoiding gluteus maximus muscle.

FIG. 14 illustrates a side-view of an exemplary tissue path through acoccyx region, for passing an end portion through tissue starting at aregion of vaginal vault tissue and extending past the rectum through atissue path proximal to the coccyx bone. The end portion can generallybe guided through such a passage prepared in muscle or other tissue,past the rectum, past and proximal to the coccyx bone, and then throughan external incision (not shown). As illustrated in FIG. 14, relevanttissue and organs include bladder 300, urethra 302, sacrum 200, coccyxbone 208, rectum 304, and vagina 308. According to this exemplaryembodiment of the invention, an implant includes tissue support portion310 contacting pelvic tissue, as illustrated including the posteriorvaginal and uterus. End portion 312 extends from tissue support portion310, through a tissue path lateral of coccyx bone 208, and to anexternal incision in the buttocks region, the tissue path preferably notpassing through gluteus maximum muscle.

FIG. 15 shows another view of a transcoccyx tissue path. As illustratedin FIG. 15, relevant tissue and organs include urethra 302, sacrum 200,coccyx bone 208, rectum 304, vagina 308, ischial spine 204,iliococcygeous muscle 230, and coccygeous muscle 232. An end portion ofan implant (not shown) can be placed to extend through a tissue paththat includes circles 310, and to an external incision.

Yet another side view of a transcoccyx tissue path is illustrated inFIG. 16, showing tissue and organs that include sacrum 200, coccyx bone208, ischial spine 204, and coccygeous muscle 232. Also shown are pubicsymphasis 312 and sacrotuberous ligament 314. According to thisillustrated embodiment of the invention, an end portion (not shown) ofan implant can be placed to extend through a tissue path that includescircle 310, and to an external incision, again preferably not passingthrough gluteus maximum muscle.

A tool can be used to install the support member, such as a tooldescribed and illustrated in U.S. patent application Ser. No.10/834,943. A useful tool generally includes a thin needle or trocharthat attaches to a handle; a handle attached to an end of the trocharand that can optionally be removable; and a tip located at at least oneend of the needle, optionally being sharp to be capable of producing apath when passed through tissue, optionally being adapted to removablyattach to the handle, and optionally being adapted to firmly yetremovably attach to an end portion of the support member. For example, atip or “dilator” (e.g., of plastic) at an end of the end portion of thesupport member may removably attach to one or both ends of the needle ortrochar, to allow the needle to push or pull the dilator through atissue passage.

A particular needle for an “inside-out” (see, e.g., below) installationprocedure for treating a female prolapse condition may include at leasttwo curved portions, e.g., two curved portions of different radii ofcurvature and also optionally of different arclengths. A proximal end ofa first curved portion can extend directly from a handle. The firstcurved portion is of a curvature and length that when inserted into thevagina can extend from the handle (located outside of the vagina) to theposterior vagina, e.g., the vaginal vault, or somewhat farther to theposterior. The first curved portion may mimic or approximate the shapeand size of the vagina, allowing the needle portion distal from thefirst curved portion to be located at or posterior to the vaginal apexor vaginal vault during insertion and use. An exemplary length(arclength) of a first curved portion can be from 5 to 7 inches, e.g.,from 5.5 to 6.5 inches. The radius of curvature of a first curvedportion can be e.g., from 3 to 7 inches, e.g., from 3.5 to 6 inches. Theradius of curvature may be substantially constant over the arclength,but may also vary by some degree.

Extending from a distal end of the first curved portion is a secondcurved portion of shorter length and a smaller radius of curvature. Thesecond curved portion can be of a length and curvature to place a distalend of the second curved portion, or an extension thereof, in positionto extend from the posterior vagina to an external incision, through acoccyx region as discussed herein (and preferably not through gluteusmaximum muscle). The second curved portion includes a somewhat sharpcorner, which is for both safety and for utility. For utility, a sharpturn causes the tip of the needle to be located near a coccyx region forcreating a transcoccyx tissue path as described. The shortened lengthand radius also improve safety because the sharper turn prevents the tipfrom inadvertently contacting sensitive tissue located above thesacrospinous ligament (and between the Alcocks's canal and the sacrum)such as nerves and vessels of the pudendal complex. An exemplary length(arclength) of a second curved portion can be from 1 to 4 inches, e.g.,from 1.5 to 3 inches. The radius of curvature of a second curved portioncan be e.g., from 0.7 to 2 inches, e.g., from 1 to 1.5 inches. Theradius of curvature may be substantially constant over the arclength ofthe second curved portion, but may also vary by some degree.

Extending from a distal end of the second curved portion is an optionalextension portion. The extension may be curved or straight, and is of alength and curvature to place a distal end or tip of the needle inposition to be located at an external incision, when the needle extendstransvaginally through the vagina, through an incision in the posteriorvagina, and through a coccyx region as discussed herein. A straightextension may be beneficial for producing a straight tissue path in thata straight needle portion may reduce trauma. Also, a straight needleportion may assist in puncturing tissue, such as stronger types oftissues, due to greater strength of a straight extension portioncompared to a curved extension portion. If a needle tip includes asurface for engaging a dilator of an end portion, a straight portion ata needle tip may be useful compared to a curved tip, especially if thesurface includes threads. The length of the extension is again based onutility and safety, with the length being selected to place the tip at adesired tissue location to create a transcoccyx tissue path and to avoidcontacting sensitive tissue such as tissue of the pudendal complex thatlies above the sacrospinous ligament. An exemplary length of this needleextension portion can be from 1 to 2 inches long, including an optionaltip with a surface for engaging a dilator, such as threads.

A tool may include any type, shape, or size of a handle. According tocertain embodiments, a handle or a portion of the length of a handle mayexhibit a non-circular form when viewed along the longitudinal axis ofthe handle. The non-circular cross-section can be, e.g., an oval,rectangle, rhombus, etc., having one dimension (e.g., maximumdimension), a “width,” that is greater than the dimension perpendicularto that “width.” A non-circular form will provide one or more surfaceson the handle for a surgeon to place pressure onto and to achieve agrip. For example a flat portion may be present for placement of a thumbnear the connection to the needle. The non-circular cross-sectional formalso defines a midplane that is a plane that includes the longitudinalaxis of the handle and extends along the width or the widest dimensionof the handle when viewed in cross section along the longitudinal axis.According to preferred tools, the handle midplane can be perpendicularto a two-dimensional plane defined by the curved needle. An exemplaryhandle may be grasped by either hand with a thumb being located in theplane of the needle and having a flat portion below the thumb, to allowthe thumb to apply pressure to the handle at the flat portion.

A non-circular handle, e.g., a handle with a midplane that isperpendicular to a two-dimensional needle, can be useful in atransvaginal inside-out procedure as described, where a needle islocated within the vagina and pelvic region of a patient and out ofview. A non-circular handle allows the user to understand the positionof the needle tip during this or another “blind” procedure based on theknown orientation between the handle and the needle tip, here atwo-dimensional needle. A handle that includes a midplane perpendicularto a two-dimensional needle can be used by a surgeon with knowledge thatthe needle tip is always located in the plane perpendicular to thehandle midplane.

FIG. 17 shows an exemplary tool for use in a transvaginal inside-outsurgical implantation procedure, the needle including two curvedportions, a straight extension, a handle having a midplane that isperpendicular to the two-dimensional plane of the needle, and a threadedtip. Tool 400 includes handle 402 having a midplane that isperpendicular to the plane of the page and to the plane defined bytwo-dimensional needle 404. Needle 404 includes a first curved portion406 extending an arclength L1 and having a radius of curvature R1 basedon center C1 of a circle defined by the curve of portion 406. Theillustration shows portion 406 not being curved immediately from theconnection to handle 402, but with a small amount of straight portion ofneedle between handle 402 and first curved portion 406; alternately,first curved portion 406 may begin immediately at the end of handle 402.Second curved portion 408 extends through an arclength L2 from a distalend of first curved portion 406. Portion 408 has a radius of curvatureR2 based on center C2 of a circle defined by the curve of portion 408.The illustration shows second curved portion 408 beginning immediatelyat the distal end of first curved portion 406, but a small amount ofstraight portion of needle may be included between first curved portion406 and second curved portion 408. Extending from a distal end of secondcurved portion 408 is straight portion 410 that terminates in tip 416,which includes threads (or another releasable engaging surface) 418.Threads 418 can be designed to engage an internal surface of a dilator,with the internal surface being either threaded or non-threaded. Handle402 includes longitudinal axis 412, and line 414 is defined by extension410 at tip 416. The angle between axis 412 and line 414 is approximately10 degrees.

An exemplary length L3 of extension portion 410 can be from 1 to 2inches long, including an optional tip with a surface for engaging adilator, such as threads.

Still referring to FIG. 17, length L4 is the distance that is thegreatest distance reached by needle 404 away from handle 402 as measuredalong axis 412. L4 can be any useful length that allows this exemplarytool to be used in an inside-out transvaginal procedure, such as atranscoccyx procedure. Examples of lengths for L4 may be from 4 to 6inches, or from 4.5 to 5.5 inches.

Length L5 is the distance between the connection of needle 404 to handle402, and tip 416, and can be any useful length that allows the tool tobe used in an inside-out transvaginal procedure, such as a transcoccyxprocedure. Examples of lengths for L5 may be from 4.5 to 6.5 inches, orfrom 5 to 6 inches.

The total length of a needle from connection to a handle to the end ofthe tip (including an engaging surface if any) may be as desired, e.g.,from 9 to 11 inches, and the total angle traversed may be up to 180degrees, meaning that the an axis of the needle through (or tangent to)the tip may point in a direction nearly parallel to the longitudinalaxis of the handle. Exemplary angles between a line extending through ortangent to a tip of a needle (see line 414 of FIG. 17) and alongitudinal axis of a handle may be, e.g., 5 to 25 degrees, or from 10to 20 degrees.

Exemplary methods of installing a support member according to theinvention, e.g., use of a tool or implant described herein, can includecertain steps described in U.S. patent application Ser. No. 10/834,943,with the understanding that certain exemplary methods and steps of theinvention can include placement of an end portion of a support member ofan implant at a tissue passage near the coccyx bone as described herein.

According to embodiments of a transvaginal surgical procedure, anincision can be made at the proximal posterior wall of the vagina, suchas a midline incision at the apex of the vagina. Another incision can bemade at the patient's exterior, i.e., an “external incision,” which canat the epidermis such as external to the coccyx region at a positionthat can allow access to a transcoccyx tissue path as discussed.Exemplary tissue paths can be made starting at the incision at thevagina, passing through tissue proximal to the coccyx (i.e., through acoccyx region), past the rectum, optionally through the coccygeous oriliococcygeus muscle, and to the external incision. The path canadvantageously avoid the gluteus maximus muscle.

Creation of the tissue path may be performed by use of a tool anddilator combination as described, which can create the tissue path andpass an end portion in a single step, or may alternately be performed byuse of a separate dissecting tool, such as a sharp trochar or needle. Asan example, a sharp tool, trochar, needle, or a sharp “pushable” dilatorattached at an end of a needle as described herein, can be used toatraumatically prepare at least a portion of a tissue path as described.The tissue path may be dissected in either direction, from the vaginalincision in the direction of the external incision, or from the externalincision in the direction of the vaginal incision. The same tool can beused to guide a tip (e.g., dilator) at the end portion of a supportmember through the tissue path and the external incision. An end portionof an implant may be led from an internal position such as at the regionof the vaginal incision, through the tissue path, and to the externalincision, by any method, and either by pushing or pulling the endportion through the tissue path. A support portion of the implant can beattached internally to tissue to be supported, at any time, before orafter positioning one or more end portions through one or more tissuepaths.

An exemplary method may be a transvaginal procedure that inserts theimplant through an incision in the vagina and then pushes one or moreend portions through one or more tissue paths starting internally andbeing dissected to an external incision in the region of the upperbuttocks and the coccyx bone. This type of procedure, whereby an endportion is pushed from an internal position to an external incision, isreferred to herein as an “inside-out” procedure.

Alternately, the procedure may insert the implant through an incision inthe vagina. A surgical tool can be passed from an external incision,through a coccyx region, and to a vaginal region. An end portion of theimplant is then associated with the tool, internally within the patient,and the tool is retracted to pull the end portion into position throughthe tissue path as the tool is withdrawn and removed. This type ofprocedure, whereby an end portion is pulled from an internal position toan external incision, is referred to herein as an “outside-in” type ofprocedure.

A particular example of an outside-in procedure may include an initialstep of inserting an elongate tool such as a needle or trocharexternally (at an external skin surface), through an external incision,and passing a tip of the tool through a coccyx region to a region at ornear the vaginal apex. A vaginal incision is prepared at the posteriorvagina for entry of an implant. The tip can be associated with an endportion of the implant at a position near the vaginal apex. The tool isretracted or removed by pulling the tool back through the tissue path,which pulls the end portion through the tissue path and through theexternal incision.

An example of an inside-out procedure may include a step of creating avaginal incision at the posterior vagina for entry of an implant and aneedle. A tip of a tool can be associated with an end portion of theimplant, while both are located exterior to the patient. In particular,a dilator attached to the end portion of the implant can be removablyengaged with a tip of an elongate insertion tool, e.g., a threadedneedle tip. Optionally, as discussed herein, the tool can be a needleand the needle can be inserted into a sheath that surrounds the endportion, either through a side aperture in the sheath or an end opening,or by puncturing the sheath with the needle tip. The needle tip (orother tool associated with the end portion) and end portion are theninserted into the vagina and passed transvaginally through the vaginalincision. The dilator is pushed using the needle handle so the dilatorcreates a tissue path that includes a coccyx region as described herein,then to an external surface or an external incision on the surface ofthe coccyx region.

A particular inside-out method can involve the use of an implant thatincludes two end portions, one end portion having a length that islonger than the length of the other end portion. Each end portion isoptionally included in a sheath as described herein, with the sheath ofthe longer end portion having a longer length. Implanting this“asymmetric” implant can include associating a needle (e.g., a needlewith two different curved portions, as also described herein) with theshorter end portion, e.g., by inserting the needle into an end openingof the sheath or a side aperture of the sheath, and leading the needlethrough the inside length of the sheath to the dilator, then engagingthe needle tip (optionally threaded) with the dilator. The needle andassociated shorter end portion are inserted into the vagina and thentransvaginally through a vaginal incision in the posterior vagina, thencan be used to create a tissue path, e.g., that traverses a coccyxregion as described herein, leading to an external incision. Thedilator, extending from the external incision, e.g., near the coccyxregion, is then disengaged from the needle tip and the needle iswithdrawn from the sheath, tissue path, and vagina, leaving the sheathand end portion within the tissue path. The shorter end portion ispositioned as desired within the tissue path and a support portion ofthe implant is located and positioned as desired at tissue to besupported, such as at the vaginal apex, or at other vaginal tissue,depending on the type of condition being treated. The amount of sheathand end portion that extend from the external incision are cut and theexternal incision may be closed, optionally with a suture to secure thedistal end of the end portion to subcutaneous tissue. At least a portionof the longer end portion remains external to the patient extending fromthe vaginal opening. The longer end portion remains external to thevagina, and includes a sheath and end portion that are longer than thoseof the shorter end portion. The added length gives the surgeonadditional material to work with after the first end portion has beeninstalled and optionally positioned as desired and secured. The longersheath may optionally include a side aperture through which the needlemay be inserted, the aperture being a distance from the dilator that isapproximately equal to the length of the sheath of the shorter endportion (i.e., the length between an end opening and a dilator of theshorter end portion). Equal distances allow the needle to be insertedthe same distance within each sheath, while engaging the dilator.(Optionally, if the sheath does not include a side aperture, the needletop may be used to puncture the sheath at any desired position, toinsert the needle to the inside of the sheath.) The second end portionis then installed through a tissue path on the opposite side of thefirst tissue path, e.g., in a coccyx region, leading to an externalincision. The needle is disengaged and removed and the second endportion can be adjusted and positioned and secured as desired.

A “one-legged” implant, such as is shown at FIG. 2, can be implantedaccording to similar steps, as can implants that include more than twoend portions.

Certain aspects of the methods and devices described herein relate totools, implants, and methods for use in installing a pelvic implant asdescribed, e.g., using one or a combination of: specific implants suchas those having various types of sheaths (with openings or sideapertures as described), end portions of different lengths, dilators ofvarious designs and configurations, or support portion configurations; atranscoccyx tissue path; or a tool having two curved portions. Ingeneral, the described tools and implants may be used for treatingvarious pelvic conditions such as urinary incontinence and prolapse,optionally but not necessarily using a transcoccyx tissue path. Certainof the described tools and implants may be particularly useful fortreating one or the other of these conditions, e.g., certain tools orimplants may be particularly useful for transvaginal installation of asupport member for treating vaginal vault prolapse. Various otheroptional features of tools or implants include the following, may alsobe useful in combination with any of the tools, implant, or methodsdescribed.

A tool may optionally include a removable handle, i.e., a handle that isattachable and removable from an end of an elongate portion of a toolsuch as a needle or trochar. A tool that includes a removable handle canallow a needle or trochar to be completely passed through tissue withoutrequiring a hole big enough to accommodate the handle. For example,certain methods of the invention can use a tool with the handle attachedto initially place the pointed tip of a needle at a desired locationthrough a vaginal incision, and then the pointed tip of the tool can bepushed through tissue and epidermis at a desired exit point to partiallyor completely establish a tissue path for an end portion of a supportmember. The handle of the tool can then be removed. An end portion of asupport member (e.g., having a plastic tip such as a removable orlocking dilator adapted to connect with and removable engage or lock tothe tool at the end from which the handle was removed) can be connectedto the end of the tool from which the handle was removed. The tool canthen be pulled through the tissue passage to pull the end portion of thesupport member through the tissue passage.

Alternately or in addition, a tool may include a needle that includes aconnection feature at an end that also can be attached to and removedfrom an implant, e.g., a needle may include a connection feature forattaching to a dilator that may then be pushed or pulled through tissueusing the needle. The connection feature allows the needle to removablyengage a dilator, or alternately may allow the dilator to be permanentlysnapped to the end of the needle, among other permanent or non-permanentengagements.

According to a general, exemplary design, a support member may include apushable dilator attached at an end of an end portion, the dilatorincluding a sharp tip design. The pushable dilator can be designed tofit the leading edge of a needle and to be pushed by the needle throughtissue to either follow or produce a path in the tissue. To produce apath in the tissue by pushing the dilator through the tissue, thepushable dilator can be sufficiently sharp and rigid to pass throughtissue when pushed with sufficient force using the needle.

A dilator (whether or not sufficiently sharp and rigid to be “pushable”)may be straight, or, according to certain specific embodiments of theinvention, may be curved in a manner that will improve manipulation ofthe dilator during a surgical procedure, e.g., in a manner that willfacilitate pushing the dilator through tissue to either produce orfollow a particular path of tissue. According to even more specificembodiments of the use of a curved dilator, the curved dilator may beused with a curved needle. Optionally, the curved shape or radius of thecurved dilator can approximate or match the curved shape or radius ofthe curved needle.

Further design features can relate to dilators and needles that includeanti-rotation or alignment features for use in various methods oftreating pelvic conditions such as prolapse and urinary incontinence, inparticular with the use of a curved needle and a curved dilator. Theanti-rotation or alignment feature may be in the form of opposing andcoordinated structural features of the dilator and the needle thattogether can: interconnect the dilator and needle to produce a desiredalignment; prevent relative movement of the two pieces such as toprevent rotation of the dilator relative to the tool; or both. Thealignment feature causes the dilator to be placed on the needle in aspecific alignment, which if the needle and dilator are both curved asdiscussed above, causes the curve of the needle to be aligned with thecurve of the dilator. An example of an alignment and anti-rotationfeature is a keyed structure, as will be understood, that includes oneor more inter-connecting surfaces and structures between the dilator andthe needle to allow the dilator to connect to the needle when the twoare properly aligned and then to also prevent rotation between the twowhen the two are connected. Other mechanical structures will also allowthe dilator to be attached at an end of a needle in a manner to producea desired alignment and to prevent rotation of the dilator relative tothe needle.

These various features of tool and support member (e.g., dilator)designs can be useful, separately or in any combinations, wheninstalling surgical articles or devices such as those of the pelvicregion, including support members to treat urinary incontinence (male orfemale) and vaginal prolapse.

According to exemplary methods, tools and support members describedherein can be useful for installing a support member to treat prolapseusing a transvaginal method and a needle path originating inside of thebody and continuing to an external location outside the body. Atransvaginal approach, and features of tool and support member designsas described such as a pushable and curved dilator and a curved needle,can allow accuracy in attaching a support member to vaginal vaulttissue, thereby improving speed and safety of the procedure.

According to certain other embodiments of methods and devices(optionally used in combination with other features described hereinsuch as a curved needle, curved dilator, pushable dilator, sheath, etc.)a support member may include only a single end portion (e.g., at anapical region). Installation of such a support member (e.g., a“single-sided support” or “one-legged implant” as shown at FIGS. 2 and3) can be faster and safer than installing a support member thatincludes two end portions for apical support. This can be particularlytrue when the end portion is to be passed through tissue of a coccyxregion, because tissue at one side of the coccyx bone is easier to reachdue to the sigmoid colon interfering with passage on the other side ofthe coccyx bone.

A dilator (e.g., a plastic tip) at an end of an end portion of a supportmember that is sufficiently rigid and pointed (e.g., sharp, conical, orthe like) to be pushed through a tissue path, e.g., atraumatically toproduce the path, allows for an alternate method of placing an endportion of a support member in a desired position. As an alternative tousing a removable handle to pull an end portion of a support memberthrough a tissue path that was previously established using a pointedneedle, a “pushable” dilator may itself be pushed through tissue toestablish a tissue path. For example, a rigid conical-shaped dilatorcould connect to an end of the needle, be inserted transvaginally tocontact tissue, and be pushed through the tissue to create a transcoccyxor other tissue path. This will establish the tissue path whilesimultaneously passing the dilator and end portion through the tissuepath, eliminating the need for a removable handle and the need for theneedle to be pulled completely through a tissue pathway establishedfirst by the needle.

An optional curved dilator as described can advantageously producereduced trauma through tissue when working around curves, because thecurved dilator can reduce or eliminate the need for sweeping of theneedle tip, and allow the operator to steer the tip by twisting thehandle of the tool. A dilator that does not rotate relative to theneedle (e.g., due to a keyed or similarly fixed connection between theneedle and the dilator) can be particularly useful with a curved needleand a curved dilator. Preventing unwanted rotation of a curved dilatorcan, for example, allow for steering of the tip by twisting the handle.

The invention also relates to the use of combinations of tools andimplants described herein, used together. As an example, the inventioncan involve a system, kit, or combination that includes any one of thedescribed implants in combination with any one of the described tools.The system may be sterilized for commercial sale and ultimate use bysurgeon. A kit or system may include, for a particular application orfor treating a particular condition such as prolapse or incontinence: asupport member (implant) and a tool designed for installing the supportmember, wherein the tool engages a dilator included as part of thesupport member. The tool and dilator features can be used for treatingvaginal prolapse, and to install surgical implants or articles that arenot related to the treatment of prolapse, such as for installingimplants (e.g., slings) for the treatment of urinary incontinence.

FIG. 18 illustrates one example of a combination or kit that includes atool 510 and a “one-legged” implant 500. Tool 510 includes a singlecurved portion 512 and tip 516 that is removably engagable with dilator506 attached to a distal end of a mesh end portion 504 and a plasticsheath surrounding mesh end portion 504.

FIG. 21 illustrates another example of a combination or kit, this oneincluding tool 550 and implant 560. Tool 550 includes handle 552 andneedle 551. Needle 551 is in two dimensions and as shown includes twocurved portions, with a tip at the distal end. Handle 552 connects to aproximal portion of needle 551 and includes a midplane perpendicular tothe plane defined by two-dimensional needle 551. Implant 560 comprisessupportive portions consisting of mesh central support portion 562located between mesh end portions 566 and 570, each end portion beinglocated within a transparent plastic sheath 564 and 568, respectively.End portion 566 is a shorter end portion compared to longer end portion570. Sheath 564 of shorter end portion 566 includes end opening 580 thatallows a needle to enter sheath 566 and be extended within sheath 566 toengage internal surface 573 of dilator 572. Alternately, a needle may beused to puncture through sheath 564 at and location on sheath 564, to beled to and engage internal surface 573 of dilator 572. Sheath 568 oflonger end portion 570 includes end opening 578, and also includes sideaperture 576. Tool 550 is shown with needle 551 inserted through sideaperture 576 into sheath 568 and extended within sheath 568 to dilator574, where a tip 575 of needle 551 is inserted to engage an internalsurface of dilator 574.

While FIG. 21 shows a single needle with a two-legged implant, theimplant could alternately be configured, used, or sold, with twoneedles, optionally with each of the two needles being pre-inserted intoa sheath with the tip of each needle engaged with the internal surfaceof the dilator at the end of each end portion.

FIGS. 22, 23, and 24, illustrate alternate embodiments of implants thatcan be useful with methods, tools, and end portion features (dilators,sheaths, different lengths) as described herein. The illustratedimplants include a tissue support portion that can be used to contactanterior tissue of the vagina and related conditions. The implants areshown to include two end portions extending in generally orsubstantially opposite directions from the anterior portion, andoptionally two end portions extending from a mid-portion of the tissuesupport portion. In addition, the implants include at least one endportion extending from the apical or posterior portion of the tissuesupport portion.

FIG. 22 illustrates mesh implant that includes tissue support portion602, which includes posterior portion 610, mid-portion 611, and anteriorportion 612, with end portions 604, 605, 606, 607, 608, and 609,attached to tissue support portion 602. Tissue support portion 602 canbe implanted to contact vaginal tissue and nearby tissue, with posteriorportion 610 being at an apical region and anterior portion 612 beinganterior, e.g., placed beneath a bladder neck. End portions 606 and 607can extend laterally, e.g., to a levator muscle. End portions 608 and609 can extend laterally and to the anterior, such as to an obturator orthrough an obturator. End portions 604 and 605 can extend to theposterior, such as through a coccyx region, through a sacrospinousligament, or through a coccyx region that includes a sacrospinousligament. As illustrated, implant 600 includes two posterior endportions, 604 and 605, but another embodiment may only include one,e.g., 604, and may be installed using only a single tissue passage tothe posterior, such as a single tissue passage through a coccyx region,through a sacrospinous ligament, or through a coccyx region thatincludes a sacrospinous ligament.

FIG. 23 illustrates mesh implant 620 that includes tissue supportportion 622, which includes posterior portion 630, mid-portion 631, andanterior portion 632, with end portions 624, 625, 628, and 629, attachedto tissue support portion 622. Tissue support portion 622 can beimplanted to contact vaginal tissue and nearby tissue, with posteriorportion 630 being at an apical region and anterior portion 632 beingplaced anteriorly, e.g., beneath a bladder neck. End portions 628 and629 can extend laterally and to the anterior, such as to an obturator orthrough an obturator. End portions 624 and 625 can extend to theposterior, such as through a coccyx region, through a sacrospinousligament, or through a coccyx region that includes a sacrospinousligament. As illustrated, implant 620 includes two posterior endportions, 624 and 625, but another embodiment may only include one endportion, e.g., 624, and may be installed using only a single tissuepassage to the posterior, such as a single tissue passage through acoccyx region, through a sacrospinous ligament, or through a coccyxregion that includes a sacrospinous ligament. See FIG. 24, whichillustrates implant 621, analogous to implant 620, but lacking a secondposterior end extension and therefore including only one posterior endextension, 624.

Example of Procedure for “One-Legged” Implant

FIGS. 18 through 20 illustrate steps of a procedure for transvaginallyinstalling a single-sided support member (i.e., a “one-legged” implantcomprising a tissue support portion and only one end portion) to treatvaginal vault prolapse.

Generally, as shown at FIG. 18, the method involves providing a supportmember 500, which includes a tissue support portion 502 (for attachmentto tissue of the vaginal vault) and a single mesh end portion 504connected to the tissue support portion. End portion 504 is a mesh endportion that is contained in a plastic transparent sheath. At the distalend of the end portion 504 (the end not connected to tissue supportportion 502), a plastic tip or “dilator” 506 is connected to mesh endportion 504 and its surrounding plastic sheath. Tool 510 is alsoprovided, e.g., as part of a kit or system with support member 500. Tool510 includes needle 512 and handle 514. Needle 512 is a single curveneedle, but may alternately include two curved portions. Needle 512includes tip 516, which engages pushable dilator 506 for passing throughor creating a tissue path. Tip 516 of needle 512 can generally bedesigned to fit or otherwise engage dilator 506 in a configuration toallow needle 512 to push dilator 506 through tissue, transvaginally,during the procedure; for example tip 516 may be threaded to engage aninternal surface of dilator 506 and allow needle 510 to push dilator506. As illustrated, dilator 506 and then end of end portion 504 are notof a low profile configuration in that dilator 506 has a major dimensionand is pushed in a direction that is perpendicular to the length-wiseaxis of end portion 504; in alternative embodiments, dilator 506 couldbe configured to be parallel with a length-wise axis of end portion 504,for easier passage through tissue of dilator 506 and the distal endportion.

An incision is provided at the posterior wall of the vagina.

A tissue path is prepared by initially dissecting the ischial spine,through the vaginal incision. The dilator is placed to engage the end ofthe needle (see FIG. 19). The needle is inserted into the externalopening of the vagina and used to place the dilator, transvaginally, ata desired position for pushing the dilator through tissue.

FIG. 20 illustrates transvaginal placement of the dilator near thecoccyx. In FIG. 20, the surgeon is holding handle 514, with a proximalportion of needle 512 being visible external to the vagina, and with theremaining needle and needle tip and implant being not visible butalready placed internal to the patient through the vagina. The needleand dilator are used to puncture muscle layers approximately 1.5 to 2.5centimeters lateral to the tip of the coccyx bone. The tissue path willrun through iliococcygeous or coccygeous muscle but not the gluteusmaximus. The path extends to the epidermis where an incision is made toallow the dilator to pass. The end portion can then be pulled throughthe tissue path externally and the tissue support portion of the supportmember can be positioned and attached to vaginal vault tissue.

Example of Insert-Molding Dilator to Distal End of End Portion andSheath

In general, a low profile end configuration of a distal end of an endportion, such as shown at FIG. 7, can be prepared by any useful method,such as by insert molding a dilator to an assembly of an end portioncontained within a sheath, the assembly being curled laterally.

A useful mold can include a combination of a sheath-forming fixture andan insert mold. FIG. 8 illustrates a portion of a mold that includes asheath-forming block 800 having side surfaces 801 that contact a secondhalf (not shown) of the block 800. A dilator can be injection molded andformed within a cavity made up of lower mold cavity 802 and a connectedupper mold cavity 804, shown in shadow (upper mold is not shown).Passage 816 is a circular passage defined by a lower end of cavity 802.Core pin 806 is inserted into passage 816 and works with cavities 802and 804 to define an internal space of a dilator for engaging a tip of aneedle. Core pin 806 includes integral collar 812 and shaft 814, and canbe mounted in block 800 to be slidable between a position that allowsend portion and sheath material to be threaded through passage 816, anda position at which collar 812 closes against a surface at the interiorperimeter of block 800 that defines passage 816.

A mold such as shown in FIG. 8 can be used to produce a dilatorconnected to a distal end of an end portion and sheath. In general, asshown in FIG. 9, a sheath and end portion assembly 820 is threadedthrough guide channel 810 and passage 816 of block 800, into lower moldcavity 802, and can be cut at the top of cavity 802, e.g., at line 818.The end of the sheath is cut at an angle (not shown) and inserted intothe bottom of the mold to thread through channel 810. As the sheath ispulled through the mold it rolls into a circular shape from thecone-shaped geometry in the mold at guide channel 810 below lower moldcavity 802. Excess sheath and end portion of assembly 820 can be cut offlevel with the top of the lower section of the mold, at line 818. Pin806 is advanced up into the rolled sheath and mesh.

As shown in FIG. 10, pin 806 is moved up into lower cavity 802 and intoupper mold cavity 804 of upper mold 822, placed in contact with theupper surface of block 800. Collar 812 seals against the bottom of lowermold cavity 802, with sheath and end portion assembly 820 being squeezedbetween collar 812 and block 800 at passage 816. The combined space ofcavities 802 and 804 is then injected with a moldable dilator materialsuch as a thermoplastic or thermosetting polymeric material using aninjection press. The connector is formed and the sheath and end portion(mesh) assembly in the lower cavity of the mold is encapsulated making asingle insert molded dilator that is connected to sheath and end portionassembly 820. The die is opened and a dilator, e.g., as shown in FIG. 7,has been attached.

1. A method for supporting vaginal tissue, the method comprising:providing an implant comprising a tissue support portion and an endportion extending from the tissue support portion, creating a vaginalincision, placing the tissue support portion in contact with vaginaltissue in a position to support the vaginal tissue, producing a tissuepath between the position of the tissue support portion and an exteriorincision, the tissue path passing through tissue of a coccyx regionbounded by an upper edge of a sacrospinous ligament, a tip of a coccyxbone, a point approximately 2.5 centimeters lateral to the tip of thecoccyx bone, and an ischial spine, associating a tip of a needle withthe end portion of the implant, and inserting the needle tip andassociated end portion into the vagina and transvaginally through thevaginal incision, and pushing the needle tip and end portion of theimplant through the tissue path and through the external incisionthereby extending the end portion through the tissue path to theexternal incision.
 2. The method of claim 1, wherein the method is fortreatment of a condition selected from vaginal vault prolapse,enterocele, rectocele, cystocele, and combinations thereof.
 3. Themethod of claim 1, wherein the tissue path passes through a coccyxregion bounded by a lower edge of a sacrospinous ligament, a tip of acoccyx bone, a point approximately 2.5 centimeters lateral to the tip ofthe coccyx bone, and an ischial spine.
 4. The method of claim 1, whereinthe tissue path passes through a coccyx region bounded by an edge of thecoccyx bone between a tip of the coccyx bone and a lower edge of asacrum, and a line 2.5 centimeters from the edge of the coccyx bonelateral and parallel to the edge.
 5. The method of claim 1, wherein thetissue path passes from a region of the vaginal apex, through coccygeousor iliococcygeous muscle, to the external incision.
 6. The method ofclaim 1, wherein the tissue path does not traverse gluteus maximusmuscle.
 7. The method of claim 1, wherein the implant comprisessupportive portions consisting of a tissue support portion and only oneend portion, and the method includes making only one tissue path betweenthe vaginal apex region and the external incision, for passing the oneend portion between the vaginal apex region and the external incision.8. A method of claim 1, further comprising using a surgical toolcomprising a handle comprising a longitudinal axis, a two-dimensionalelongate needle extending from the handle, the elongate needlecomprising a first curved portion proximal to the handle, the firstcurved portion having a first radius of curvature and a first arclength,a second curved portion extending from a distal end of the first curvedportion, the second curved portion having a second radius of curvatureand a second arclength that are different from the first radius ofcurvature and first arclength, and and a straight portion extending froma distal end of the second curved portion to a needle tip.
 9. The methodof claim 1, wherein the implant comprises a dilator at an end of the endportion distal from the tissue support portion, the dilator capable ofcooperating with the insertion tool to push or pull the dilator throughtissue.
 10. The method of claim 1, wherein the implant comprises anelongate sheath surrounding at least a portion of an end portion, and adilator attached at a distal end of the sheath.
 11. A method of treatinga pelvic condition, the method comprising providing an implantcomprising supportive portions consisting of a central support portionhaving two opposing sides and two opposing ends and a shorter endportion extending from one end of the central support portion and alonger end portion extending from the opposing end of the centralsupport portion wherein the central support portion has a width greaterthan a width of the end portions, and the shorter end portion has alength that is shorter than a length of the longer end portion providinga tool comprising a curved needle, a tip of the needle adapted to engagea distal end of an end portion, contacting the tissue support portionwith a pelvic tissue, engaging the tool with a distal end of the shorterend portion and implanting the shorter end portion in a patient, andafter implanting the shorter end portion, engaging the tool with adistal end of the longer end portion and implanting the longer endportion in the patient.
 12. The method of claim 11, for treating vaginalvault prolapse.
 13. A method of implanting a pelvic implant, the methodcomprising providing an implant comprising: a tissue support portion andfirst and second elongate end portions extending from the tissue supportportion, a first and second dilator attached to a distal end of each endportion, first and second elongate sheaths surrounding at least aportion of each end portion, the sheaths comprising a distal endattached to the dilator, wherein the end portions include a passageinside of the sheaths, to an internal surface of each dilator, providinga tool comprising an elongate needle having a needle tip adapted toengage the internal surface of the dilators through the passages,placing the tool inside at least a portion of the first sheathsurrounding a length of the first end portion, and engaging the firstdilator, inserting the first dilator through a first tissue path bypushing the first dilator using the tool.
 14. The method of claim 13,further comprising: disengaging the first dilator from the needle tip,withdrawing the needle from the first tissue path, after withdrawing theneedle from the first tissue path, inserting the needle into the sheathof the second end portion surrounding a length of the second end portionand engaging a second dilator with the needle tip, and inserting thesecond dilator through a second tissue path by pushing the seconddilator using the tool.
 15. A method for supporting vaginal tissue, themethod comprising providing an implant comprising a tissue supportportion and an end portion extending from the tissue support portion,creating a vaginal incision, placing the tissue support portion incontact with vaginal tissue in a position to support the vaginal tissue,producing a tissue path between the position of the tissue supportportion and an exterior incision, the tissue path passing through tissueof a coccyx region bounded by an upper edge of a sacrospinous ligament,a tip of a coccyx bone, a point approximately 2.5 centimeters lateral tothe tip of the coccyx bone, and an ischial spine, extending the endportion through the tissue path to the external incision, wherein theimplant comprises supportive portions consisting of a tissue supportportion and only one end portion, and the method includes making onlyone tissue path between the vaginal apex region and the externalincision, for passing the one end portion between the vaginal apexregion and the external incision.